Distal Insertion Rupture of Lateral Ankle Ligament as a Predictor of Weakened and Delayed Sports Recovery after Acute Ligament Repair: Mid- to Long-Term Outcomes of 148 Cases

Background: Surgical repair has been considered for ankle sprain patients with high sports demanding to achieve stronger ankle stability and allow for an earlier return to sports. However, there is a lack of systematic research regarding arthroscopic treatment followed by ligament repair for severe acute ankle sprain. The purpose of this study was to analyze the mid- to long-term outcome of arthroscopy followed by open anatomic lateral ankle ligament repair surgery for acute lateral ankle sprain and the impact of ligament rupture site on the outcome. Methods 166 professional or semi-professional athletes with clinically- and radiologically-confirmed grade III acute lateral ankle ligament injuries underwent ankle arthroscopy followed by open anatomic ligament repair. Intra-articular lesions and rupture site of the lateral ankle ligament were treated and explored under arthroscopy. Simple suture repair was performed for mid- substance ligament rupture (middle group), while suture repair with anchors were used for the ruptures near the ligament attachment site on the fibular (proximal group), talar or the calcaneal side (distal group). The evaluation parameters included VAS score, AOFAS score, Tegner score, time to return to sports and resumption of pre-injury sports level at final follow-up, sprain recurrence and range of motion (ROM). Results The mean follow-up duration was 64.5 (range, 37–132 months) months and 148 (89.2%) patients were evaluated at final follow-up. Intra-articular lesions were treated under arthroscopy in 63 (43%) patients. The average time to return to pre-injury sports activity was 4.37 ± 1.10 months and 17 (11.5%) patients complaint sprain recurrence after operation. There were 71 (48%) cases in the proximal group, 46 (31%) cases in the middle group and 31 (21%) cases in the distal group respectively. The proximal group achieved shortest time to return to sports (4.14 ± 1.09 months) and highest resumption proportion of pre-injury sports level (94% ± 11%) at final follow-up, followed by middle group (89% ± 15%, 4.61 ± 0.93 months, respectively) and distal group (87% ± 13%, 4.53 ± 1.29 months, respectively) ( p =0.008, p =0.04, respectively). At final follow-up, all of the VAS score, AOFAS score and the Tegner score were significantly improved from the pre-operative level (p < 0.001). 18 (12%) patients reported mild ROM restriction and 7 (4.7%) patients experienced transient skin numbness. Conclusions Ankle arthroscopy followed by open anatomic ligament repair is a reliable procedure for patients with high sports demands after severe acute ankle sprains. Rupture near the talar or calcaneal side weakened the sports resumption and delayed about 2 weeks of sports recovery.